LAPORAN PENDAHULUAN

ASUHAN KEPERAWATAN Ny. “S”

DENGAN DIAGNOSA MEDIS CA MAMAE
Di Ruang Bougenvile 4 RSUP Dr. Sardjito Yogyakarta

Disusun Oleh :

RAMADIN
NIM: PN.17.0109

PROGRAM STUDI ILMU KEPERAWATAN & NERS

SEKOLAH TINGGI ILMU KESEHATAN WIRA HUSADA
YOGYAKARTA
2017
 ASUHAN KEPERAWATAN
PADA NY. “S” DENGAN DIAGNOSA MEDIS CA MAMAE
DI RUANG BOUGENVILE 4
RSUP DR. SARDJITO YOGYAKARTA

Asuhan Keperawatan ini telah dibaca dan diperiksa pada

Hari/tanggal: .................................................

Pembimbing Klinik Mahasiswa Praktikan

(Erlina Sulistiowati, S.Kep., Ns) (RAMADIN)

Mengetahui,
Pembimbing Akademik

(Doni Setiyawan, S.Kep., Ns., M.Kep)

 ASUHAN KEPERAWATAN Ny. “S”
DENGAN DIAGNOSA MEDIS CA MAMAE DI RUANG BOUGENVILE 4
RSUP DR. SARDJITO YOGYAKARTA

Hari/Tgl Pengkajian : Senin, 18 Desember 2017 Jam : 08.00

Nama Mahasiswa : RAMADIN
NIM : PN.17.0109
Rumah Sakit / Ruang : RSUP Dr. Sardjito / Bougenvile 4

A. IDENTITAS
1. Klien
Nama : ............................... Tgl Masuk RS : ........................
Tempat tanggal lahir : ............................... Sumber Data : ........................
Jenis Kelamin : .............................. No RM : ........................
Agama : .............................................................................................
Status Perkawinan : .............................................................................................
Pendidikan : .............................................................................................
Pekerjaan : .............................................................................................
Suku / Bangsa : .............................................................................................
Alamat : .............................................................................................
Dx Medis : .............................................................................................

2. Penanggung Jawab Klien

Nama : .............................................................................................
Umur : .............................................................................................
Jenis Kelamin : .............................................................................................
Pendidikan : .............................................................................................
Pekerjaan : .............................................................................................
Alamat : .............................................................................................
Hubungan dengan pasien : .............................................................................................

B. RIWAYAT KESEHATAN
1. Riwayat Kesehatan Klien
a) Keluhan Utama :
......................................................................................................................................
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 b) Riwayat Penyakit Sekarang :
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c) Riwayat Penyakit Dahulu :
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2. Riwayat Kesehatan Keluarga :
a) Genogram

b) Riwayat Penyakit Keluarga

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C. PENGKAJIAN PEMENUHAN KEBUTUHAN DASAR MANUSIA (11 POLA GORDON)

1. Pola Persepsi dan Pemeliharaan Kesehatan
.............................................................................................................................................
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2. Pola Nutrisi
Sebelum Sakit
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.............................................................................................................................................
Selama Sakit
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3. Pola Eliminasi
Sebelum Sakit
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Selama Sakit
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4. Pola Aktivitas dan Latihan
a. Sebelum Sakit
.....................................................................................................................................
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.....................................................................................................................................
.....................................................................................................................................
b. Selama Sakit
1) Penilaian kemampuan klien dalam beraktivitas selama sakit (beri tanda √)

Kemampuan perawatan diri 0 1 2 3 4

Makan minum
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi ROM

0 = Mandiri
1 = Dengan Alat Bantu
2 = Dibantu orang lain
3 = Dengan alat bantu dan dibantu orang lain
4 = Ketergantungan total
 Kesimpulan :
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5. Pola Tidur dan Istirahat
Sebelum Sakit
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Selama Sakit
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6. Sensori, Persepsi dan Kognitif
Sebelum Sakit
.............................................................................................................................................
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.............................................................................................................................................
Selama Sakit
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7. Konsep Diri
a) Identitas Diri
......................................................................................................................................
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......................................................................................................................................
b) Harga Diri
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c) Peran Diri
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8. Seksual dan Reproduksi
Sebelum Sakit
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.............................................................................................................................................
Selama Sakit
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 9. Pola Peran Hubungan
Sebelum Sakit
.............................................................................................................................................
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.............................................................................................................................................
Selama Sakit
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10. Manajemen Koping Stress
Sebelum Sakit
.............................................................................................................................................
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.............................................................................................................................................
Selama Sakit
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11. Sistem Nilai dan Keyakinan
Sebelum Sakit
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Selama Sakit
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D. PEMERIKSAAN FISIK
1. Keadaan Umum
a) Tingkat Kesadaran : GCS : E= V= M=
b) Status Gizi :
TB :
BB :
Penilaian Status Gizi :
c) Tanda Vital
Tekanan Darah :
Frekuensi Nadi :
Suhu :
Respirasi Rate :
SpO2 :
2. Pemeriksaan Fisik Sistemik
a) Kepala
Bentuk dan kulit kepala
......................................................................................................................................
......................................................................................................................................
Rambut
......................................................................................................................................
......................................................................................................................................
Kesan wajah
......................................................................................................................................
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b) Mata, Telinga, Hidung
Mata
......................................................................................................................................
......................................................................................................................................
Telinga
......................................................................................................................................
......................................................................................................................................
Hidung
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c) Mulut
Bibir
......................................................................................................................................
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Gigi
......................................................................................................................................
......................................................................................................................................
Lidah
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......................................................................................................................................
Tenggorokan
......................................................................................................................................
......................................................................................................................................
d) Leher
Inspeksi
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......................................................................................................................................
Palpasi
......................................................................................................................................
......................................................................................................................................
e) Dada/thoraks
Jantung
Inspeksi :
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Palpasi :
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......................................................................................................................................
Perkusi :
......................................................................................................................................
......................................................................................................................................
Auskultasi :
......................................................................................................................................
......................................................................................................................................
Paru-Paru
Inspeksi :
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Palpasi :
......................................................................................................................................
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Perkusi :
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Auskultasi :
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f) Payudara
Inspeksi :
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Palpasi :
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g) Abdomen
Inspeksi :
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Auskultasi :
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 Perkusi :
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Palpasi :
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h) Genetalia
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i) Ekstremitas
Atas :
Inspeksi
......................................................................................................................................
......................................................................................................................................
Palpasi
......................................................................................................................................
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Bawah :
Inspeksi
......................................................................................................................................
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Palpasi
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j) Kulit
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E. PEMERIKSAAN PENUNJANG
1) Laboratorium

Hari/
tanggal/ Jenis Pemeriksaan Hasil Nilai Normal Interpretasi
jam

2) Radiologi
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3) EEG, USG, MRI, EKG
......................................................................................................................................
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4) Scanning
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F. TERAPI MEDIS YANG DIDAPAT

No Nama Obat Dosis Fungsi Rute

G. ANALISA DATA

Data Problem Etiologi

H. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS MASALAH

1. .............................................................................................................................................
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2. .............................................................................................................................................
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3. .............................................................................................................................................
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4. .............................................................................................................................................
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5. .............................................................................................................................................
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 RENCANA ASUHAN KEPERAWATAN

Nama Klien : Ruang : Diagnosa Medis :

No RM : Umur :

Perencanaan
No Hari/Tgl/Jam Dx. Keperawatan
Tujuan dan Kriteria Hasil Intervensi
NOC : NIC :
 Perencanaan
No Hari/Tgl/Jam Dx. Keperawatan
Tujuan dan Kriteria Hasil Intervensi
 CATATAN PERKEMBANGAN

Nama Klien : Ruang : Diagnosa Medis :

No RM : Umur :

Evaluasi Nama
No
Hari,Tanggal Implementasi &
Dx Proses Hasil Ttd
 Evaluasi Nama
No
Hari,Tanggal Implementasi &
Dx Proses Hasil Ttd